THE ROYAL AUSTRALIAN COLLEGE OF GENERAL PRACTITIONERS RACGP Immunisation Position Paper Aim The prevention of disease through vaccination is readily available to all Australian children Principles Prevention of disease by immunisation is a safe and cost effective population health measure that provides long term protection from the morbidity and mortality caused by vaccine preventable diseases. Providing immunisation is a core General Practice activity; 70% of all immunisations in Australia are provided in General Practice. It is an important preventive activity considered by the World Health Organisation to be highly cost-effective and usually cost saving. 1 In order for the public health benefits to be maximised, immunisation rates of 90-95% need to be achieved. Qualitative research has shown that public uptake of health recommendations is greatest where: government health departments make and promulgate a public recommendation government provides funds to make relevant vaccines freely available GPs make personal recommendations to their patients. 2 Background The gains in population health resulting from the introduction of sanitation and a clean water supply in industrialised countries were extended in the 20th century, by the increasing availability of vaccines against infectious diseases. The Australian record for childhood immunisations has improved dramatically since 1996 through a coordinated and strategic approach to immunisation. In 1996, the level of childhood vaccination was 56% as recommended in the Australian Standard Vaccination Schedule (ASVS). This level was insufficient to prevent outbreaks of vaccine preventable disease, and unsatisfactory compared to international World Health RACGP immunisation position paper 1
Organisation (WHO) standards. The 2003 level stands at more than 90% of one-year-old children fully vaccinated, and more than 82% of six-year-olds are fully vaccinated. (ACIR data). Some 97% of all Australians support immunisation and see it as a health benefit. 3 These improvements were made by a combination of strategies instituted from January 1996, which included the setting up of national databases that register all ASVS childhood immunisations given before the child turns seven years old, and provide information that can then be used to generate reminders of due and overdue vaccinations at practice level. These databases are the Australian Childhood Immunisation Register (ACIR) and the Queensland Vaccination Information and Vaccine Administration System (VIVAS). The General Practice Immunisation Incentive scheme (GPII) uses ACIR data to generate service incentive and outcome payments, as well as ACIR notification reporting fees to GPs. Parents were also given financial incentives to have their children fully immunised via increased maternity allowance payments and child-care subsidies. GPs were encouraged to bulk-bill services that provided childhood immunisations, particularly to those patients on health care cards and pensioners. These national immunisation strategies recognised GPs' essential role in improving vaccination rates, and their need for ready access to free vaccines and current immunisation-related information. All vaccines recommended on ASVS from 1996 to mid-2003 were essentially fully funded by the federal health department. In September 2003 provision of some recommended vaccines has been restricted to limited and specified population groups, such as the ATSI population and children with pre-disposing conditions. Most parents, however, will be required to pay for some recommended vaccines. Efficient, reliable information systems at practice, state and national levels facilitate systematic and complete vaccination of all Australian children from birth to six years of age. Position of the RACGP At the strategic level, the RACGP: Supports the systematic and effective immunisation of all children and adults against vaccine preventable diseases as recommended by the NHMRC Australia Considers that the RACGP, ADGP, ACRRM, AMA and the government must work together to ensure that immunisation programs have full funding to enable equity of access to health provision and immunisation for all. All peak agencies should recognise and support the essential role played by general practice RACGP immunisation position paper 2
Recognises Australia has achieved great advances in the prevention of vaccine preventable diseases by funding systemic approach to increasing immunisation rates Wishes to cooperate and collaborate with Divisions of General Practice and other immunisation providing organisations in order to improve immunisation services Supports certification of vaccination status for school and childcare entry as of public health benefit. In relation to financing an effective immunisation model, the RACGP: Supports the government funding of all vaccinations recommended for Australian children by the National Health and Medical Research Council (NHMRC) on the basis of high quality evidence of their health benefit, thus removing barriers to achieving best practice effective immunisation: Supports the continuation of GPII Supports continuation of financial incentives for parents who have their children fully immunised. Recommends changes to the Medical Benefits Schedule to allow fee for service payment for immunisations as a procedural item, removing financial disincentive when provided by practice nurses, facilitating more GPs to employ practice nurses. In relation to standards for an effective immunisation model, the RACGP: Endorses the NHMRC Australian Immunisation Handbook, and the Standards for Childhood Immunisation as guidelines Endorses the operation of ACIR and VIVAS and would like to see both extended to a "whole of life" approach Has incorporated evidence of immunisation records as a performance indicator of provision of opportunistic preventive care into the Entry Standards for General Practice (Standard 1.6.3). 4 In relation to implementing an effective immunisation model, the RACGP: Supports the role of practice nurses in immunisation and acknowledges the benefits and advantages of using accredited practice nurses to provide immunisations in General Practice Recognises that practice nurses have a professional role to play in improving service delivery and the quality of heath care immunisation programs in the general practice setting Recognises that Divisions of General Practice have an important role in education and quality assurance in relation to immunisation and in helping GPs establish practice systems which promote immunisation Encourages medical software suppliers to include information about vaccinations in printable format Believes immunisation publications such as the immunisation handbook and myths and realities of immunisation are essential resources for GPs. RACGP immunisation position paper 3
The RACGP: Does not support compulsory vaccination measures Notes that homeopathic "immunisation" is not effective and cannot be supported. Recommended Role for Individual GPs GPs have a responsibility to advise each patient about the benefits and risks of those vaccinations that are indicated for each patient, based on current knowledge of best practice. GPs need support and assistance to deal with, and counter, the anti-immunisation lobby. Any GP who does not support immunisation has a responsibility to inform patients of their position and to provide a referral. GPs should be familiar with and immunise in accordance with the latest edition of the NHMRC Australian Immunisation Handbook. GPs should be aware that the technique of split-dosing vaccines or mixing vaccines in the same syringe for administration, or using non-recommended vaccination sites cannot be supported. GPs should monitor the immunisation status of their patients by means of immunisation records and reminder systems. Computerised practice systems facilitate such monitoring. GPs should promptly notify appropriate childhood immunisations to the ACIR or VIVAS. GPs should promptly notify cases of notifiable disease to appropriate state and territory health departments. GPs should promptly notify significant adverse events following immunisation to appropriate state and territory health departments and Adverse Drug Reaction Australian Committee (ADRAC) GPs must maintain the effectiveness of the vaccines used by continuing to monitor the "cold chain" management of their offices. The best vaccine storage temperature is 5 degrees C plus or minus 3 degrees. Strategies The RACGP will use its National Standing Committee structure and authorised representatives to contribute to and monitor: the national immunisation strategy ACIR, GPII and the degree to which they are user friendly outcomes of the national strategy, including the role of GPs, in achieving targets set. RACGP immunisation position paper 4
The RACGP will use its authorised representatives to cooperate and collaborate with the Divisions of General Practice, as both organisations provide complementary roles in the national immunisation strategy. The RACGP will provide feedback to members and to the Federal government. The RACGP will participate in the production and distribution of educational information for GPs and consumers. 1. Hinman AR. Economic aspects of vaccines and immunizations. C R Acad Sci III 1999;322:989-94. 2. Pareek M, Pattison HM. The two-dose measles, mumps, and rubella (MMR) immunisation schedule: factors affecting maternal intention to vaccinate. Br J Gen Pract 2000;50:969-71.. Forrest JM, Burgess MA, McIntyre PB. Factors influencing vaccination uptake. Workshop report. Current Australian research on the behavioural, social and demographic factors influencing immunisation, Royal Alexandra Hospital for Children, Sydney, March 1998. Commun Dis Intell 2000;24:51-3. Bartlett MJ, Burgess MA, McIntyre PB, Heath TC. Parent and general practitioner preferences for infant immunisation. Reactogenicity or multiple injections? Aust Fam Physician 1999;28 Suppl 1:S22-7. 3. Hull B, Lawrence G, MacIntyre RC and McIntyre P (2002) Immunisation coverage: Australia 2001. Canberra, DoHA. 4. The Royal Australian College of General Practitioners 2000 Entry Standards for General Practitioners 2nd ed.racgp, South Melbourne References Bartlett MJ, Burgess MA, McIntyre PB, Heath TC. Parent and general practitioner preferences for infant immunisation. Reactogenicity or multiple injections? Aust Fam Physician 1999;28 Suppl 1:S22-7. Forrest JM, Burgess MA, McIntyre PB. Factors influencing vaccination uptake. Workshop report. Current Australian research on the behavioural, social and demographic factors influencing immunisation, Royal Alexandra Hospital for Children, Sydney, March 1998. Commun Dis Intell 2000;24:51-3. Hinman AR. Economic aspects of vaccines and immunizations. C R Acad Sci III 1999;322:989-94. Pareek M, Pattison HM. The two-dose measles, mumps, and rubella (MMR) immunisation schedule: factors affecting maternal intention to vaccinate. Br J Gen Pract 2000;50:969-71. The Royal Australian College of General Practitioners 2000 Entry Standards for General Practitioners 2nd ed. RACGP, South Melbourne RACGP immunisation position paper 5
Publication Date: 17 December 2003 Authorised By: Office of the CEO and President RACGP immunisation position paper 6